Moshe Pritsch

Monteggia and equivalent lesions. A study of 41 cases.

Forty-one patients who suffered from a Monteggia fracture and were treated between 1984 and 1993 were reviewed retrospectively using a new motion score of the elbow joint. There were 14 children and 27 adults of whom 34 were available for review. The results in children were significantly better than those of the adults. Among the adults, the final results of the patients who had a Bado Type 1 equivalent injury were significantly worse than those of the other groups, especially when associated with a fracture of the radial head. The type of fracture, open or closed, the presence of a fracture of the olecranon, and the energy level of the trauma did not have any significant prognostic value. Good correlation was shown between the new motion score and the Figgie elbow score. The Bado Type 1 equivalent injuries should be considered as a special subgroup of the Monteggia lesion, necessitating extra attention in treatment and rehabilitation, and a close followup of the patient.

Therapeutic embolization for late hemarthrosis after total knee arthroplasty: A case report

Late spontaneous hemarthrosis occurs in 0.3% to 1% of patients who have undergone total knee arthroplasty 1,2. In a study of thirty knees with spontaneous hemarthrosis, Kindsfater and Scott reported that the mean interval between the arthroplasty and the first occurrence of bleeding was 24.2 months (range, two weeks to 144 months) 2. Excluding coagulopathy, the most common cause of spontaneous hemarthrosis after total knee arthroplasty is trauma to the hypertrophic vascular synovium or infrapatellar fat pad caused by impingement of those structures between the articulating prosthetic components 1,3-6. Other, less common causes are diffuse pigmented villonodular synovitis, arteriovenous fistula, and bleeding from a genicular artery 3,5,7,8. To our knowledge, only two cases of late spontaneous hemarthrosis after total knee arthroplasty attributable to active bleeding from a genicular artery have been reported. In one, the patient was taking warfarin regularly and was treated with embolization 7. In the other, the patient had a normal coagulation profile and was treated with arthrotomy and ligation of the bleeding vessel 8. We present a case of hemarthrosis that occurred six years after a total knee arthroplasty in a patient with no bleeding diathesis and that was treated successfully with catheter embolization of the genicular artery. Our patient was notified that data concerning the case would be submitted for publication. A healthy eighty-one-year-old woman with osteoarthritis had undergone bilateral serial total knee arthroplasties one year apart. There …

Primary reconstruction of traumatic bony defects using allografts.

Abstract We retrospectively reviewed 207 patients suffering from traumatic bone defect who had been treated at our institution between 1973 and 1993. Three types of traumatic bone defects were identified: I, minor; II, major cortical; III, major articular. Each type was further subdivided into: A, open injury; B, closed injury. The proposed treatment modality of each type was included within each classification. Types II and III posed the greatest difficulties in management. However, massive bone allografts can be successfully used in these situations, even in the early phases of treatment, but only given specific prerequisites.

A wide and versatile combined surgical approach to the shoulder

Complex injuries and conditions of the shoulder may necessitate wide exposure during the operative procedure. The commonly used approach today is a wide anterior deltopectoral approach with extensive detachment of the deltoid muscle, leading to muscle damage, which may result in difficult postoperative rehabilitation and deteriorated function. We describe a simple combined approach that consists of a deltopectoral approach in conjunction with a subcutaneously performed lateral deltoid split with a single skin incision. We believe this surgical technique provides another useful tool to achieve wide and versatile exposure of the shoulder without jeopardizing the function of either the deltoid muscle or axillary nerve.

Osteochondritis of the first metatarsal sesamoids

SummaryOsteochondritis of the sesamoids of the hallux is an infrequently presenting condition of uncertain etiology. The diagnosis is usually established by the typical clinical presentation, fragmentation of the affected sesamoid seen on the axial-view radiogram and increased uptake on the 99mTc bone scan. The condition is usually refractory to conservative treatment and is best treated by excision of the affected sesamoid.

Composite grafts in the treatment of osteosarcoma of the proximal humerus

Treatment of osteosarcoma (OSA) of the proximal humerus poses many difficulties and challenges to the treating team. Between 1993 and 2000, we treated 11 patients (three women, eight men; age range, 17–74 years) suffering from OSA of the proximal humerus by ‘composite’: massive allografts and long humeral prosthesis. At presentation, 10 patients were at stage 2-B and one at stage 3-B of OSA. One patient presented with a pathologic fracture. All patients except patient No. 6, received preoperative chemotherapy followed by limb salvage surgery and postoperative chemotherapy.Surgical margins were graded as wide in all patients. Postoperative complications included non-union at the allograft/host junction (which united after auto grafting) and superficial wound infections that resolved after antibiotic therapy. All surgical procedures were performed by a team headed by an orthopedic oncologist and shoulder surgeon. At latest follow-up (December 2001) all patients, with the exception of one (who was at stage 3-B at presentation) were alive, and had good function of the upper limb. It is our opinion that the team approach comprising an orthopedic oncologist and shoulder surgeon greatly contributed to the good surgical outcome, and hence the good survival and functional results of the patients. Bone allograft offers a modular malleable durable solution to the resected bone segment.

An unusual fracture of the base of the fifth metatarsal bone.

An unusual fracture of the base of the fifth metatarsal bone is described. The type of fracture and the displacement of the proximal fragment was unlike that of most other fractures of this region of the foot. It requires open reduction and internal fixation which was successfully carried out by means of tension wires.

Patients education of a self-reduction technique for anterior glenohumeral dislocation of shoulder.

BACKGROUND : Anterior dislocation of the shoulder (glenohumeral joint) is one of the most prevalent dislocations. Following a first dislocation recurrence rates of up to 80% have been reported. Many patients will seek medical assistance for reduction of the shoulder after each of these recurrent dislocations. We describe the results of reduction of anterior glenohumeral dislocation using a modified self manipulated Milch technique that can be performed by the patients themselves after simple guidance and demonstration. This method is directed to patients who are not willing or cannot have surgical stabilization and may be in a place where medical assistance is not available. PATIENTS : The patient is placed in a supine position, and begins slowly to actively abduct and externally rotate the dislocated shoulder until the arm is overhead. Once the overhead position has been achieved, the arm is gently lowered back to the side of the body. Simultaneously, the patient has to apply pressure to the front of the shoulder with the other hand to maintain position until the reduction is complete. RESULTS : Thirty-two dislocated shoulders in 33 consecutive patients suffering from recurrent dislocations were successfully reduced by this technique. Mean reduction time was 10 minutes. DISCUSSION : The results illustrate the fact that most patients are able to reliably and reproducibly reduce glenohumeral dislocations by themselves. Subsequent dislocations can be reduced promptly decreasing the dislocation time thus avoiding further damage to the shoulder, achieving immediate pain relief, and removing the immediate necessity for medical attendance.

Use of botulinum neurotoxin injections to treat recurrent shoulder dislocations in a patient with severe epilepsy: a case report.

The treatment of a shoulder dislocation sustained during an epileptic seizure can be a challenge to the orthopaedic surgeon. Severe drug-resistant epilepsy with multiple seizures may cause repeated dislocations of the shoulder, resulting in damage to the joint capsule and the glenoid. Any attempt at reconstructive surgery of the shoulder requires complete control of the seizures and prevention of dislocations for at least three months following the surgical procedure. We report our experience with one patient who had recurrent dislocations of the right shoulder due to uncontrollable seizures; we treated this patient with botulinum neurotoxin type A to prevent the dislocations. The patient was informed that data concerning her case would be submitted for publication, and she provided consent. The case report was approved by our institutional review board. A twenty-three-year-old woman had been diagnosed with acute intermittent porphyria and severe epilepsy at the age of fourteen. She had had repeated tonic-clonic seizures, which were unresponsive to therapy with multiple drugs (sodium valproate, carbamazepine, vigabatrin, sulthiame, clonazepam, levetiracetam, and topiramate). She had undergone implantation of a vagus nerve stimulator, which did not control the seizures but did shorten the postictal period. At the age of sixteen, the patient had sustained anterior glenohumeral dislocations of both shoulders during a seizure. By the time she was referred to our care at the age of nineteen, she had a chronic dislocation of the left shoulder and recurrent dislocations of the right shoulder. A computerized tomography (CT) examination of the right shoulder …

The significance of the axial foot projection in the diagnosis of metatarsal pathology.

SummaryMetatarsalgia is a symptom and not a disease. Three cases, as examples, are presented to highlight the need for axial roentgenograms of the forefoot in order to elicit the pathology missed by regular posterior-anterior and lateral roentgenograms.ZusammenfassungMetatarsalgie ist ein Symptom, nicht eine Krankheit. Am Beispiel von drei Fällen wird gezeigt, daß axiale Röntgenbilder des Vorfußes nötig sind, um pathologische Zustände auszuschließen, die bei den üblichen posterior-anterioren und lateralen Röntgenbildern übersehen werden.